Implicit and Explicit Attitudes of Medical Students Towards Mental Illness: A Randomized
Controlled Pilot Trial of Service User Videos to Reduce Stigma in Nepal

Background: Many health providers worldwide stigmatize people living with mental illness,
creating a barrier to providing quality mental health services. Interventions aiming
to reduce stigma during medical school have utilized education and contact-based methods
to improve student attitudes towards mental illness. However, the effectiveness of
these methods has never before been compared in medical schools in low-income countries.
The aim of this study was to evaluate a video featuring a mental health service user
with depression in a randomized controlled pilot trial among medical students in Nepal.
Methods: In a three-armed randomized controlled pilot trial, participants were randomized
to one of three conditions: a didactic video lecture based on the mental health Gap
Action Programme Implementation Guide (mhGAP-IG) depression module, a service user
testimonial video about living with depression, and a condition with no video presentation.
Participants were 94 second and third year medical students in Nepal. All of the measures
were collected post-intervention. The primary outcome was explicit attitudes measured
on the Social Distance Scale (SDS). Additional outcomes were implicit attitudes on
two Implicit Association Tests (IAT), diagnostic accuracy, treatment knowledge, and
symptom knowledge. Results: Both the didactic lesson (SDS mean score, M = 33.32; standard
deviation, SD = 9.57) and the service user videos (M= 30.13; SD= 9.16) had lower explicit
stigma after the video presentations compared to the control (M= 39.10; SD= 11.14)
(F2,91= 6.37, p= 0.003, R2= 0.12), but there was no difference between the two intervention
conditions (F1,61= 1.55, p= 0.23, R2= 0.02). There were no significant differences
on implicit associations (IAT d score), depression diagnosis, treatment knowledge,
and symptom knowledge. Conclusions: Prerecorded videos (whether didactic or service
user testimonials) are scalable learning tools that have potential to reduce explicit
stigma among medical students in low resources settings. Additional research is necessary
to explore the differences between both didactic education and service user testimonial
interventions, as well as the potential outcomes when the videos are combined. A full
scale randomized controlled trial will be conducted based on these findings.